Current concepts in meniscal suturing techniques: indications, advantages, and limitations

The meniscus is critical for load distribution and joint stability; tears disrupt biomechanics and accelerate cartilage degeneration, prompting a shift from meniscectomy toward preservation and repair. We review three core techniques - inside-out, outside-in, and all-inside - with stepwise descriptions, indications, advantages/limitations, devices, and complication profiles. Inside-out offers precise, strong fixation but requires an accessory incision and neurovascular precautions; outside-in is reproducible and cost-efficient for anterior horn tears; and all-inside reduces soft-tissue dissection and operative time, improving access to posterior/body regions. No single meniscal repair technique demonstrates clear superiority in healing or failure rates; outcomes depend on tear characteristics and patient factors. Although modern all-suture all-inside devices show favorable biomechanics, their higher cost and unclear cost-effectiveness limit definitive clinical advantage. Technical pearls include optimized portal placement, peripheral bites, protection of neurovascular structures, and avoidance of soft-tissue bridges. Concomitant ACL reconstruction enhances healing - likely via improved stability and marrow-derived biologic augmentation. Region-specific guidance is provided using medial and lateral anatomical zoning, aligning suture patterns (inside-out, outside-in, and all-inside) to tear location to preserve biomechanics and reduce complications.